Qualified Investment for Community Investment Tax Credit

DHCD Community Investment Tax Credit Program

QUALIFIED INVESTMENT FOR COMMUNITY INVESTMENT TAX CREDIT

Individuals, corporationsand other entities that make a qualified investment to an awarded Community Development Corporation (CDC) or Community Support Organization (CSO), referred to as a Community Partner,or to a Community Partnership Fund will earn tax credits equal to fifty percent (50 %) of the total qualified investment made by the taxpayer, subject to the limits prescribed in M.G.L.c. 62, §6M and c. 63, §38 EE. The Massachusetts Department of Housing and Community Development (DHCD) will issue aCITC interim certificationin a form to be completed by the taxpayer for submission to the Massachusetts Department of Revenue which, in turn, will issue a Tax Credit Certificate.

PART I –QUALIFIED INVESTMENT TAXPAYER INFORMATION:(This section is to be completed by the corporation, individual or other entitymaking the qualified investment.)

Amount of qualified investment: $ (minimum amount is $1,000)

Date of Investment: / /20

Taxpayer’s business type or status: (check the category which best applies; check only one)

Form CITC

April 2014 Page 1 of 5

DHCD Community Investment Tax Credit Program

001–Construction

002–Accounting Services

003–Transportation/Communications/Utilities

004–Wholesale/Retail Trade

005–Finance Institution

006–Insurance/Real Estate

007–Business Services

008–Health Services

009–Legal Services

010–Education Services

011–Individual

012–Other (describe):

Form CITC

April 2014 Page 1 of 5

DHCD Community Investment Tax Credit Program

Name and address of recipient Community Partner or Partnership Fund:

Island Housing Trust Corporation

Did this taxpayer make a contribution to the same Community Partner in 2013? YesNo

If yes, amount of 2013 contribution: $

Taxpayer(s) relationship to Community Partner:

I/we have received and or expect to receive payment for goods or services in excess of $1,000 from this Community Partner in this year or the preceding year. Yes No

If yes, describe the contractual relationship with the Community Partner and the goods and services provided.

Tax year of taxpayer, as reported to IRS. (If a fiscal year, please provide dates.)

Calendar Year (January-December)Fiscal Yearto

TAXPAYER INFORMATION: (This section is to be completed by the Community Partner or Community Partnership Fund (United Way of Massachusetts Bay) for any taxpayer that is an individual, entity, or pass-through entity claiming the credit at the entity level. Note: For any partner, shareholder, beneficiary, or other owner of a pass-through entity taxpayer who is claiming the credit in lieu of the pass-through entity donor, skip this section and complete Other Claimant Information.

1. Taxpayer (Name):

1. Title (if applicable):

1. Name of Business: (if applicable):

1. Address (City, State, Zip):

1. Telephone number:

Is the taxpayer above a pass-through entity? Yes No

If yes, will the credit be claimed at the entity level? Yes No

Type of pass-through entity/taxpayer:

Trust Partnership Corporation S Corporation, or ____Other (describe)

______

(If Applicable)

OTHER CLAIMANT INFORMATION: (This section is to be completed by the Community Partner or Community Partnership Fund (United Way of Massachusetts Bay) in consultation with the managing partner, managing shareholder, managing member, or trustee, or the partner, shareholder, beneficiary, or other owner of a pass-through entity taxpayer who is claiming the credit in lieu of the pass-through entity taxpayer. Note: Every claimant of a pass-through entity must provide proper documentation that indicates their pro rata share or other allocation of the credit. Examples of such documentation may include a trust instrument, a partnership agreement, articles of incor­poration, or a current list of all members of an LLC, as required by MGL Ch. 156C, sec. 9.) Note Also: The sum of the allocable credit to each claimant must equal the total allowable credit.

1. Claimant (Name):

Claimant address:

Pro rata share or other amount of allowable credit:% .

1. Claimant (Name):

Claimant address:

Pro rata share or other amount of allowable credit: % .

1. Claimant (Name):

Claimant address:

Pro rata share or other amount of allowable credit: % .

1. Claimant (Name):

Claimant address:

Pro rata share or other amount of allowable credit: % .

NOTICE AND WAIVER: The statuteauthorizing the Community Investment Tax Credit Program (CITC), requires the Department of Housing and Community Development to make information available to the Department of Revenue and vice-versa, including identification of the Community Partner, the type and amount of Qualified Investment, and the Taxpayer identity. In signing this Qualified Investment Certification, the Community Partner and the Taxpayer acknowledge this obligation and to the extent necessary, waive any rights to confidentiality in this or related information.

DISCLAIMER: The tax credit is based on the taxpayer’s eligibility under Program requirements and under tax laws or other requirements affecting the taxpayer. The Department of Housing and Community Development, the Community Partnerand the Fund Administrator, make no representations about tax consequences in connection with a particular Qualified Investment.

I/we hereby certify that I/we are not an employee of the above-named Community Partner. I/we further certify that this qualified investment is not being made by another Community Partner designated by DHCD. I/we also certify that if we disclosed receipt of payment for goods and services from this Community Partner in excess of $1,000, this qualified investment is entirely independent of such relationship.

Submitted by: (Name of taxpayer):

PART II – COMMUNITY PARTNER OR FUND ADMINISTRATOR:(This section is to be completed by the Community Partner or the Partnership Fund Administrator, as applicable.)

I have examined this application and all attachments and attest to an accurate description of the value of the Investment(s) received by our organization from the taxpayer named herein for the purpose of carrying out the approved Community Investment Plan for the Community Investment Tax Credit Program.

Name of Community Partner or Fund Administrator:Island Housing Trust Corporation

Name of Community Partner, if submitted by Fund Administrator, on their behalf:

Contact Name: Philippe Jordi

(Print Name and Title)

Email: Phone: 508.693.1117

Qualifying Investment Amount: $ Date Received:

Required documentation attached: (check all that apply)

Copy of Thank You Letter/Acknowledgement of Investment from Community Partner or Fund Administrator

Other (Describe:)

NOTICE AND WAIVER: The statuteauthorizing the Community Investment Tax Credit Program (CITC), requires DHCD to make information available to the Department of Revenue and vice-versa, including identification of the Community Partner, the type and amount of Qualified Investment, and the Taxpayer identity. In signing this Qualified Investment Certification, the Community Partner and the Taxpayeracknowledge this obligation and to the extent necessary, waive any rights to confidentiality in this or related information.

DISCLAIMER:The tax credit is based on the taxpayer’s eligibility under Program requirements and under tax laws or other requirements affecting the taxpayer. The Department of Housing and Community Development, the Community Partnerand the Fund Administrator, make no representations about tax consequences in connection with a particular Qualified Investment.

I hereby certify, to the best of my knowledge, that the above-named taxpayer is not an employee of the above-named Community Partner. I further certify that to the best of my knowledge, that this qualified investment is not being made by another Community Partner designated by DHCD. I also certify, to the best of my knowledge, that if receipt of payment for goods and services from this Community Partner in excess of $1,000is disclosed above, this qualified investment is entirely independent of such relationship.

Contact Name:Philippe Jordi

(Print)

Signature: ______Date: ______

SEND COMPLETED FORM AND REQUIRED DOCUMENTATION TO: Massachusetts Department of Housing and Community Development, Community Investment Tax Credit Program, 100 Cambridge St., Suite 300, Boston, Massachusetts 02114.dhcd

Form CITC

April 2014 Page 1 of 5